Bruno do Valle Pinheiro

Recomendações brasileiras de ventilação mecânica 2013. Parte I

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associacao de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in Sao Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.

Traqueostomia precoce versus traqueostomia tardia em pacientes com lesão cerebral aguda grave

OBJECTIVE: To compare the effects of early tracheostomy and of late tracheostomy in patients with acute severe brain injury. METHODS: A retrospective study involving 28 patients admitted to the ICU of the Federal University of Juiz de Fora University Hospital in Juiz de Fora, Brazil, diagnosed with acute severe brain injury and presenting with a Glasgow coma scale (GCS) score < 8 within the first 48 h of hospitalization. The patients were divided into two groups: early tracheostomy (ET), performed within the first 8 days after admission; and late tracheostomy (LT), performed after postadmission day 8. At admission, we collected demographic data and determined the following scores: Acute Physiology and Chronic Health Evaluation (APACHE) II, GCS and Sequential Organ Failure Assessment (SOFA). RESULTS: There were no significant differences between the groups (ET vs. LT) regarding the demographic data or the scores: APACHE II (26 ± 6 vs. 28 ± 8; p = 0.37), SOFA (6.3 ± 2.7 vs. 7.2 ± 3.0; p = 0.43) and GCS (5.4 ± 1.7 vs. 5.5 ± 1.7; p = 0.87). The 28-day mortality rate was lower in the ET group (9% vs. 47%; p = 0.04). Nosocomial pneumonia occurring within the first 7 days was less common in the ET group, although the difference was not significant (0% vs. 23%; p = 0.13). There were no differences regarding the occurrence of late pneumonia or in the duration of mechanical ventilation between the groups. CONCLUSIONS: On the basis of these findings, early tracheostomy should be considered in patients with acute severe brain injury.

Precisão do diagnóstico clínico da síndrome do desconforto respiratório agudo quando comparado a achados de necropsia

OBJECTIVE To compare the American-European Consensus Conference (AECC) definition of acute respiratory distress syndrome (ARDS) to autopsy findings. METHODS All patients who died in the intensive care unit of the Federal University of Juiz de Fora University Hospital between 1995 and 2003 and were submitted to autopsy were included in the study. Patient clinical charts were reviewed to establish whether cases met the AECC criteria for a diagnosis of ARDS, histologically defined as the presence of diffuse alveolar damage (DAD). RESULTS During the study period, 592 patients died, and 22 were submitted to autopsy. Of those 22 patients, 10 (45%) met the AECC criteria, and 7 (32%) met the histopathological criteria for DAD. The AECC clinical criteria presented a sensitivity of 71% (95%CI: 36-92%) and a specificity of 67% (95%CI: 42-85%). The positive and negative predictive values were, respectively, 50 and 83%, whereas the positive and negative likelihood ratios were, respectively, 2.33 and 0.47. The histopathological findings in the 5 patients who met AECC criteria but did not present DAD were pneumonia (n = 2), pulmonary embolism (n = 1), tuberculosis (n = 1), and cryptococcosis (n = 1). CONCLUSION The accuracy of the AECC definition of ARDS was godless than satisfactory. Due to the low positive predictive value and the low positive likelihood ratio, other hypotheses must be considered when ARDS is suspected.

Constant Work-Rate Test to Assess the Effects of Intradialytic Aerobic Training in Mildly Impaired Patients With End-Stage Renal Disease: A Randomized Controlled Trial

OBJECTIVE To investigate if high-intensity constant work rate (CWR) would constitute a more appropriate testing strategy compared with incremental work rate (IWR) to assess the effectiveness of intradialytic aerobic training in patients with end-stage renal disease (ESRD). DESIGN Randomized controlled trial. SETTING Nephrology unit at the university hospital. PARTICIPANTS Patients (N=28; 47.0±11.9y) under hemodialysis (4.4±4.3y) were randomly assigned to exercise and control groups. INTERVENTION Patients included in the exercise group underwent a moderate-intensity intradialytic aerobic training program 3 times per week for 12 weeks. MAIN OUTCOME MEASURES Cardiopulmonary and perceptual responses were obtained during an IWR and a high-intensity CWR test to the limit of tolerance on a cycle ergometer. RESULTS Training-induced increases in peak oxygen uptake (Vo(2)peak) and time to exercise intolerance (Tlim). Mean improvement in Tlim (97.4%±75.6%) was significantly higher than increases in Vo(2)peak (12%±11.3%) (P<.01); in fact, while Tlim improved 50% to 200% in 9 of 12 patients, Vo(2)peak increases were typically in the 15% to 20% range. CWR test revealed lower metabolic, ventilatory, cardiovascular, and subjective stresses at isotime; in contrast, submaximal responses during the incremental work rate (at the gas exchange threshold) remained unaltered after training. CONCLUSIONS A laboratory-based measure of endurance exercise capacity (high-intensity CWR test to Tlim) was substantially more sensitive than oxygen uptake at the peak IWR test to unravel the physiologic benefits of an intradialytic aerobic training program in mildly impaired patients with ESRD.

Lesao pulmonar de reperfusao

A lesao de isquemia-reperfusao constitui-se em um evento fisiopatologico comum a diversas doencas da pratica clinica diaria. O pulmao pode ser alvo da lesao de isquemia-reperfusao diretamente, como no edema pulmonar apos transplante ou na resolucao de tromboembolismo; ou ainda ser atingido a distância, como nos casos de choque ou por lesao de reperfusao em intestino ou em membros inferiores, como ocorre no pincamento da aorta, utilizado nas cirurgias de aneurisma. Dentre os mediadores envolvidos na lesao de isquemia-reperfusao, foram identificados especies reativas toxicas de oxigenio (ERTO), mediadores lipidicos, como a tromboxana, moleculas de adesao em neutrofilos e endotelio, fator de necrose tumoral, dentre outros. As medidas terapeuticas para a lesao de reperfusao ainda sao utilizadas no plano experimental e em poucos estudos clinicos. Sao utilizados: antioxidantes, bloqueadores de mediadores lipidicos, inibidores da interacao entre leucocito e endotelio ou substâncias que favorecam o fluxo sanguineo pos-isquemico.

Efeito do exercício aeróbico durante as sessões de hemodiálise na variabilidade da frequência cardíaca e na função ventricular esquerda em pacientes com doença renal crônica

INTRODUCAO: Pacientes com doenca renal cronica (DRC) sob tratamento hemodialitico apresentam diminuicao da variabilidade da frequencia cardiaca (VFC) que representa um fator de risco independente para a mortalidade cardiaca, especialmente a morte subita. OBJETIVO: Avaliar o efeito do exercicio aerobico, realizado durante as sessoes de hemodialise, na VFC e na funcao ventricular esquerda de pacientes portadores de DRC. METODOS: Foram avaliados 22 pacientes randomizados em dois grupos: exercicio (n = 11; 49,6 ± 10,6 anos; 4 homens) e controle (n = 11; 43,5 ± 12,8; 4 homens). Os pacientes do grupoexercicio foram submetidos a tres sessoes semanais de exercicio aerobico, realizado nas duas horas iniciais da hemodialise, durante 12 semanas. Para a analise da VFC e da funcao ventricular esquerda, todos os pacientes foram submetidos aos exames de Holter de 24 horas e ecocardiograma, respectivamente. RESULTADOS: Apos 12 semanas de protocolo, nao foi observada diferenca significante em nenhum dos parametros da VFC nos dominios do tempo e da frequencia em ambos os grupos. A fracao de ejecao aumentou de modo nao significante nos pacientes do grupo-exercicio (67,5 ± 12,6% vs. 70,4 ± 12%) e diminuiu nao significantemente nos pacientes do grupo-controle (73,6 ± 8,4% vs. 71,4 ± 7,6%). CONCLUSAO: A realizacao de 12 semanas de exercicio aerobico, durante as sessoes de hemodialise, nao modificou a VFC e nao promoveu melhora significante na funcao ventricular esquerda.

Anemia in Inflammatory Bowel Disease Outpatients: Prevalence, Risk Factors, and Etiology

Anemia is common in inflammatory bowel disease (IBD). However, epidemiological studies of nonwestern IBD populations are limited and may be confounded by demographic, socioeconomic, and disease-related influences. This study evaluated the prevalence, risk factors, and etiology of anemia in Brazilian outpatients with IBD. Methods. In this cross-sectional study, 100 Crohns disease (CD) patients and 100 ulcerative colitis (UC) subjects were assessed. Anemia workup included complete blood count, ferritin, transferrin saturation, serum levels of folic acid and vitamin B12, and C-reactive protein (CRP) concentration. Results. The overall prevalence of anemia in IBD was 21%. There was no significant difference in the prevalence of anemia between CD subjects (24%) and UC (18%). Moderate disease activity (OR: 3.48, 95% CI, 1.95–9.64, P = 0.002) and elevated CRP levels (OR: 1.8, 95% CI, 1.04–3.11, P = 0.02) were independently associated with anemia. The most common etiologies of anemia found in both groups were iron deficiency anemia (IDA; 10% on CD and 6% on UC) followed by the anemia of chronic disease (ACD; 6% for both groups). Conclusions. In Brazilian IBD outpatients, anemia is highly concurrent condition. Disease moderate activity as well as increased CRP was strongly associated with comorbid anemia. IDA and/or ACD were the most common etiologies.

Pulmonary function and exercise tolerance are related to disease severity in pre-dialytic patients with chronic kidney disease: a cross-sectional study

BackgroundChronic kidney disease (CKD) involves a progressive, irreversible loss of kidney function. While early-stage CKD patients may show changes in pulmonary function and lowered exercise tolerance, the role of the estimated glomerular filtration rate (eGFR) in these patterns remains unknown. The aim of this study was to investigated pulmonary function and exercise tolerance in pre-dialytic CKD patients.MethodsA cross-sectional study was carried out with 38 adult volunteers divided into a control group (CG), consisting of 9 healthy adults, and 29 pre-dialytic CKD patients in stages 3 (G3), 4 (G4), and 5 (G5). All participants underwent spirometric and manovacuometric tests, a cardiopulmonary exercise test (CPET), a 6-minute walk test (6MWT), and laboratory tests.ResultsThe significant differences was observed in maximal exercise tolerance, measured as peak oxygen consumption percentage (VO2peak) (mL/kg/min) (CG = 28.9 ± 7.8, G3 = 23.3 ± 5.6, G4 = 21.4 ± 5.2, G5 = 20.2 ± 6.9; p = 0.03), and submaximal exercise tolerance, measured by 6MWT (m) (CG = 627.6 ± 37.8, G3 = 577.4 ± 66.1, G4 = 542.7 ± 57.3, G5 = 531.5 ± 84.2, p = 0.01). The eGFR was associated with pulmonary function-forced expiratory volume in the first second percentage (FEV1) (%) (r = 0.34, p = 0.02) and maximum inspiratory pressure (PImax) (r = 0.41, p = 0.02) - and exercise tolerance - VO2peak (mL/kg/min) (r = 0.43, p = 0.01) and 6MWT distance (m) (r = 0.55, p < 0.01).ConclusionPre-dialytic CKD patients showed lower maximal and submaximal exercise tolerances than healthy individuals.

Physical Activity in Hemodialysis Patients Measured by Triaxial Accelerometer

Different factors can contribute to a sedentary lifestyle among hemodialysis (HD) patients, including the period they spend on dialysis. The aim of this study was to evaluate characteristics of physical activities in daily life in this population by using an accurate triaxial accelerometer and to correlate these characteristics with physiological variables. Nineteen HD patients were evaluated using the DynaPort accelerometer and compared to nineteen control individuals, regarding the time spent in different activities and positions of daily life and the number of steps taken. HD patients were more sedentary than control individuals, spending less time walking or standing and spending more time lying down. The sedentary behavior was more pronounced on dialysis days. According to the number of steps taken per day, 47.4% of hemodialysis patients were classified as sedentary against 10.5% in control group. Hemoglobin level, lower extremity muscle strength, and physical functioning of SF-36 questionnaire correlated significantly with the walking time and active time. Looking accurately at the patterns of activity in daily life, HDs patients are more sedentary, especially on dialysis days. These patients should be motivated to enhance the physical activity.

Diarréia nosocomial em unidade de terapia intensiva: incidência e fatores de risco

RACIONAL: Diarreia nosocomial parece ser comum em unidades de terapia intensiva, embora sua epidemiologia seja pouco documentada em nosso meio. OBJETIVO: Determinar a incidencia e fatores de risco de diarreia entre pacientes adultos internados em unidade de terapia intensiva. METODOS: Foram incluidos prospectivamente 457 pacientes no periodo entre outubro de 2005 e outubro de 2006. Dados demograficos, clinicos e bioquimicos, bem como aspecto e numero de evacuacoes eram registrados diariamente ate a saida do paciente do setor. RESULTADOS: Diarreia ocorreu em 135 (29,5%) pacientes, durando em media 5,4 dias. O tempo do seu inicio em relacao a internacao foi de 17,8 dias e casos similares de diarreia no mesmo periodo foram registrados em 113 (83,7%) pacientes. A mortalidade hospitalar foi maior nos pacientes com diarreia do que naqueles sem esta intercorrencia. Na analise multivariada atraves de modelo de regressao logistica, apenas o numero de antibioticos (OR 1,65; IC 95% = 1,39-1,95) e o numero de dias de antibioticoterapia (OR 1,16; IC 95% = 1,12-1,20) associaram-se estatisticamente com a ocorrencia de diarreia. Cada dia de acrescimo a mais da antibioticoterapia aumentou em 16% o risco de diarreia (IC 12% a 20%), enquanto a adicao de um antibiotico a mais ao esquema antimicrobiano aumentou as chances de ocorrencia de diarreia em 65% (IC 39% a 95%). CONCLUSAO: A incidencia de diarreia nosocomial na unidade de terapia intensiva e elevada (29,5%). Os principais fatores de risco para sua ocorrencia foram numero de antibioticos prescritos e duracao da antibioticoterapia. Alem das precaucoes entericas, a prescricao judiciosa e limitada de antimicrobianos, provavelmente reduzira a ocorrencia de diarreia neste setor.